Business Insurance Property Owners

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1 Business Insurance Property Owners Insurance Application & Proposal Intermediary Interim Cover No. The Proposer Insured Name Business/Trading Name Are you registered for GST purposes? Yes No What is your ABN Postal Address Postcode Contact No. Phone Fax Mobile Address Website Other Interested Parties Period of Insurance From To General Information A. Have You, in the last 5 years 1. made any claim(s) on an insurer for loss or damage? Yes No 2. had any insurance declined or cancelled, proposal/ application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer? 3. suffered any loss or damage which would have been covered by the proposed insurance policy? B. Have You or Your Partners or Directors 1. ever been declared bankrupt? Yes No 2. in the last 10 years been involved in a company or business which became insolvent or was under the control of a liquidator or receiver? 3. been convicted of any criminal offence or served a prison sentence? Yes No If you answered YES to any question in (A) or (B) above, please provide full details in the space below Yes Yes Yes No No No

2 Details of the Property Location(s) Postcode Construction Details Number of Stories Age Walls Brick/Concrete % Timber % Iron% Floors Roof If any EPS panelling, what percentage of total building area? Are the Premises National Trust or Heritage Listed? Yes No Is the premise currently occupied? Yes No By whom? Tenant/Owner Occupied/Owner If your property is multi-tenanted, please show the occupation of each tenant Protection Are there Fire Sprinklers? Yes No Single/Dual Supply Area Coverage % Fire Detectors? Yes No Heat/Thermal/Both Area Coverage % Burglary Protection Deadlocks on all external doors Bars/grills on all external windows Monitored Back to Base Alarm Local Alarm only Do You, the Tenant Store or use any dangerous substances? Yes No Use any process that uses heat? Yes No If Yes, Please provide details

3 Section 1 - Fire and Perils Sum Insured Buildings (including costs of fees, removal of debris) $ Landlords Fixtures and Fittings $ All Other Property $ Do you want Replacement Cover for Building? Yes No Section 2 - Profits Part A - Loss of Income Indemnity Period Months Expected Income/Rentals $ Part B - Claim Preparation Costs $ Part C - Records $ Part D - Extra Costs $ Part E - Debts $ Section 3 - Accidental Damage Covers the items insured under Section 1 $ Section 4 - Burglary Landlords Fixtures and Fittings $ All other Property $ Section 5 - Glass External and Internal Glass Yes No External Glass ONLY Yes No Glass or Plastic Signs $

4 Section 6 - Money 1. In Transit $ 2. At the location during Your Business Hours $ 3. In a locked safe or strongroom at the location when your business is closed $ 4. In a building at the location when Your Business is closed $ 5. Your or an Employee s home $ Section 7 - Engineering Part A - Machinery Breakdown (Please enter the number of units you have) Air-Conditioning, Electronic Motors, Ventilations and Exhaust Systems Group 1 - Rated power per unit 10 kilowatts or less No. of Units $5,000 Per Unit Group 2 - Rated power 10 to 30 kilowatts per unit No. of Units $5,000 Per Unit Part B - Boiler (All units must be registered) Sum Insured $ Type, Make and Model of Boiler Power of each Boiler 1 Kilowatts 2 Kilowatts 3 Kilowatts Section 8 - Electronics Please show the Make and Model of Equipment to be covered Sum Insured 1 Sum Insured $ 2 Sum Insured $ 3 Sum Insured $ 4 Sum Insured $ Optional Extensions (Please enter the number of units you have) 1. Cover anywhere in Australia. Please list the item numbers Section 9 - Employee Theft Not applicable under this Property Owners Cover Section 10 - Portable Items Not applicable under this Property Owners Cover

5 Section 11 - Transit Not applicable under this Property Owners Cover Property Owners Liability Insurance If you have selected Property Owners Liability Insurance please complete this section. (A separate Property Owners Liability Insurance Policy will be issued) Limit of Indemnity Required Public Liability - Limit any one occurrence $ Products Liability Not Insured Claims History Please give full details of all Claims and/or complaints made against You in he past five (5) years Important Notices Your Duty of Disclosure This policy is subject to The Insurance Contracts Act Under that Act You have a Duty of Disclosure. This means: 1. When You ask for cover, You must tell Us all that You know about the risk that You want covered which may affect Our decision: (a) To offer You cover, and (b) The terms and the cost of such cover. 2. If You ask for the cover to be renewed, extended, altered or reinstated You must tell Us: (a) If there have been any changes in what is covered, and (b) Of all things that may increase the chances of a claim. What You Don t Have to Tell Us You do not have to tell Us of anything; 1. That reduces the chances of a claim. But, if You do, it may let Us offer You better terms. 2. That is common knowledge. 3. That we should know as a normal part of Our business. 4. If We waive Your Duty of Disclosure. Non-Disclosure If You don t tell Us something that You know which may affect Our decision to offer You cover or the terms of that cover We may be allowed to: 1. Reduce the amount that We have to pay for a claim. This may mean that We would pay You nothing. 2. Cancel this policy. We may even be allowed to cancel this policy from the date that the cover started if You lie to Us or deliberately keep information from Us or mislead Us.

6 By signing this Proposal form You declare that: Declaration 1. You have read the above Important Notices 2. You understand and have complied with Your Duty of Disclosure. 3. The property that You want covered is in good condition. 4. All the information You have given in this form is correct. Please sign below Signature Date Title/Position

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